A 56-year-old previously healthy woman with no other past medical history is post-operative day one from an open reduction and internal fixation of a fractured right radius and ulna after a motor vehicle accident. What is one of the primary ways of preventing postoperative pneumonia in this patient?

In-hospital intravenous antibiotics

Three hours after undergoing open proctocolectomy for ulcerative colitis, a 42-year-old male complains of abdominal pain. The pain is localized to the periumbilical and hypogastric regions. A total of 20 mL of urine has drained from his urinary catheter since the end of the procedure. Temperature is 37.2°C (98.9°F), pulse is 92/min, respirations are 12/min, and blood pressure is 110/72 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 99%. Physical examination shows a 20 cm vertical midline incision and an ileostomy in the right lower quadrant. There is no fluid drainage from the surgical wounds. The urinary catheter flushes easily and is without obstruction. Cardiopulmonary examination shows no abnormalities. Serum studies show a blood urea nitrogen of 30 mg/dL and a creatinine of 1.3 mg/dL. Which of the following is the most appropriate next step in management?

Administer intravenous furosemide

A 19-year-old woman with no known past medical history presents to the emergency department with increasing lower pelvic pain and vaginal discharge over the last several days. She endorses some experimentation with marijuana and cocaine, drinks liquor almost daily, and smokes 2 packs of cigarettes per day. The patient's blood pressure is 84/66 mm Hg, pulse is 121/min, respiratory rate is 16/min, and temperature is 39.5°C (103.1°F). Physical examination reveals profuse yellow-green vaginal discharge and severe cervical motion tenderness. What is the most appropriate definitive treatment for this patient’s presumed diagnosis?

Clindamycin + gentamicin × 14 days

Levofloxacin and metronidazole × 14 days

A 70-year-old man with a 2 year history of Alzheimer disease is brought in from his nursing facility with altered mental status and recurrent falls during the past few days. Current medications include donepezil and galantamine. His vital signs are as follows: temperature 36.0°C (96.8°F), blood pressure 90/60 mm Hg, heart rate 102/min, respiratory rate 22/min. Physical examination reveals several lacerations on his head and extremities. He is oriented only to the person. Urine and blood cultures are positive for E. coli. The patient is admitted and initial treatment with IV fluids, antibiotics, and subcutaneous prophylactic heparin. On the second day of hospitalization, diffuse bleeding from venipuncture sites and wounds is observed. His blood test results show thrombocytopenia, prolonged PT and PTT, and a positive D-dimer. Which of the following is the most appropriate next step in the management of this patient's condition?

Immediately cease heparin therapy and prescribe an alternative anticoagulant

Cryoprecipitate, FFP and low dose SC heparin

Four hours after undergoing an abdominal hysterectomy, a 43-year-old woman is evaluated in the post-anesthesia care unit because she has only had a urine output of 5 mL of blue-tinged urine since surgery. The operation went smoothly and ureter patency was checked via retrograde injection of methylene blue dye mixed with saline through the Foley catheter. She received 2.4 L of crystalloid fluids intraoperatively and urine output was 1.2 L. She had a history of fibroids with painful and heavy menses. She is otherwise healthy. She underwent 2 cesarean sections 8 and 5 years ago, respectively. Her temperature is 37.4°C (99.3°F), pulse is 75/min, respirations are 16/min, and blood pressure is 122/76 mm Hg. She appears comfortable. Cardiopulmonary examination shows no abnormalities. There is a midline surgical incision with clean and dry dressings. Her abdomen is soft and mildly distended in the lower quadrants. Her bladder is slightly palpable. Extremities are warm and well perfused, and capillary refill is brisk. Laboratory studies show: Leukocyte count 8,300/mm3 Hemoglobin 10.3 g/dL Hematocrit 31% Platelet count 250,000/mm3 Serum _Na+ 140 mEq/L _K+ 4.2 mEq/L _HCO3+ 26 mEq/L _Urea nitrogen 26 mg/dL _Creatinine 1.0 mg/dL Urine _Blood 1+ _WBC none _Protein negative _RBC none _RBC casts none A bladder scan shows 250 mL of retained urine. Which of the following is the next best step in the evaluation of this patient?

Return to the operating room for emergency surgery

Perform ultrasound of the kidneys

Administer 20 mg of IV furosemide

Administer bolus 500 mL of Lactated Ringers

Three days after undergoing coronary artery bypass surgery, a 72-year-old man has severe right upper quadrant pain, fever, nausea, and vomiting. He has type 2 diabetes mellitus, benign prostatic hyperplasia, peripheral vascular disease, and chronic mesenteric ischemia. He had smoked one pack of cigarettes daily for 30 years but quit 10 years ago. He drinks 8 cans of beer a week. His preoperative medications include metformin, aspirin, simvastatin, and finasteride. His temperature is 38.9°C (102°F), pulse is 102/min, respirations are 18/min, and blood pressure is 110/60 mmHg. Auscultation of the lungs shows bilateral inspiratory crackles. Cardiac examination shows no murmurs, rubs or gallops. Abdominal examination shows soft abdomen with tenderness and sudden inspiratory arrest upon palpation in the right upper quadrant. There is no rebound tenderness or guarding. Laboratory studies show the following: Hemoglobin 13.1 g/dL Hematocrit 42% Leukocyte count 15,700/mm3 Segmented neutrophils 65% Bands 10% Lymphocytes 20% Monocytes 3% Eosinophils 1% Basophils 0.5% AST 40 U/L ALT 100 U/L Alkaline phosphatase 85 U/L Total bilirubin 1.5 mg/dL Direct 0.9 mg/dL Amylase 90 U/L Abdominal ultrasonography shows a distended gallbladder, thickened gallbladder wall with pericholecystic fluid, and no stones. Which of the following is the most appropriate next step in management?

Intravenous piperacillin-tazobactam therapy and percutaneous cholecystostomy

Intravenous heparin therapy followed by embolectomy

Careful observation with serial abdominal examinations

Endoscopic retrograde cholangiopancreatography with papillotomy

A 33-year-old woman comes to the emergency department because of severe right flank pain for 2 hours. The pain is colicky in nature and she describes it as 9 out of 10 in intensity. She has had 2 episodes of vomiting. She has no history of similar episodes in the past. She is 160 cm (5 ft 3 in) tall and weighs 104 kg (229 lb); BMI is 41 kg/m2. Her temperature is 37.3°C (99.1°F), pulse is 96/min, respirations are 16/min and blood pressure is 116/76 mm Hg. The abdomen is soft and there is mild tenderness to palpation in the right lower quadrant. Bowel sounds are reduced. The remainder of the examination shows no abnormalities. Her leukocyte count is 7,400/mm3. A low-dose CT scan of the abdomen and pelvis shows a round 12-mm stone in the distal right ureter. Urine dipstick is mildly positive for blood. Microscopic examination of the urine shows RBCs and no WBCs. 0.9% saline infusion is begun and intravenous ketorolac is administered. Which of the following is the most appropriate next step in management?

Extracorporeal shock wave lithotripsy

Postoperative complications in gynecologic surgery for USMLE Step 3: High-Yield Surgery Lessons

🎭 The Unwanted Encore

Immediate (<24h):
- Hemorrhage: ↓BP, ↑HR. Check CBC, coagulation studies. May require fluid resuscitation, transfusion, or return to OR.
- Ureteral/Bladder/Bowel Injury: Often iatrogenic. Suspect with flank pain, hematuria, oliguria, or peritonitis.
Early (24h - 30d):
- Infection: Surgical Site Infection (SSI), UTI, pelvic abscess.
- Venous Thromboembolism (VTE): DVT/PE. Prophylaxis is key.
- Ileus: Common; prolonged if >3-5 days.
- Wound Dehiscence/Evisceration: Surgical emergency.
Late (>30d):
- Adhesions: Can lead to chronic pain or small bowel obstruction.
- Fistula: Vesicovaginal (painless, continuous watery discharge), Rectovaginal.
- Incisional Hernia, Pelvic Organ Prolapse.

⭐ Post-op Fever Workup: Remember the 5 W's: Wind (Atelectasis, POD 1-2) Water (UTI, POD 3-5) Wound (SSI, POD 5-7) Walking (VTE, POD 7+) Wonder drugs (Anytime)

🚩 Clinical Manifestations - Reading the Red Flags

Hemorrhage/Hematoma: Tachycardia, hypotension, ↓ Hct, oliguria. Presents with vaginal bleeding, a palpable pelvic mass, or flank pain (retroperitoneal).
Infection (SSI/Abscess): Fever > 38°C after POD #2, leukocytosis.
- SSI: Localized erythema, induration, purulent drainage.
- Abscess: Persistent fever despite antibiotics, localized pain, ileus.
Thromboembolism (DVT/PE):
- DVT: Unilateral leg swelling, pain, erythema.
- PE: Sudden dyspnea, pleuritic chest pain, tachycardia, hypoxia.
Urogenital Injury:
- Ureteral: Flank pain, fever, ileus, ↑ Cr.
- Bladder/Fistula: Hematuria, oliguria, or continuous watery vaginal discharge.

CT: Post-hysterectomy pelvic abscess with gas and fluid

⭐ 📌 Mnemonic for Post-Op Fever ("5 Ws"):

Wind (Atelectasis): POD 1-2

Water (UTI): POD 3-5

Walk (DVT/PE): POD 4-6

Wound (SSI): POD 5-7

Wonder Drugs/What did we do? (Abscess, Drug Fever): >POD 7

🕵️‍♀️ Diagnosis - The Clinical Detective

📌 5 W's of Post-Op Fever:

Wind (Atelectasis/PNA): POD 1-2. Dx: Chest X-ray.
Water (UTI): POD 3-5. Dx: Urinalysis, culture.
Wound (SSI): POD 5-7. Dx: Exam (erythema, drainage), CT for deep abscess.
Walking (DVT/PE): POD >5. Dx: Doppler US, CT Angiography.
Wonder Drugs/Abscess: POD >7. Dx: Review meds, CT scan.

Hemorrhage: Assess vitals, CBC. Pelvic US for hematoma; CT-A for active extravasation.
Urogenital Injury:
- Ureter: ↑Cr, flank pain. Dx: CT urogram, retrograde pyelogram.
- Bladder: Gross hematuria. Dx: Retrograde cystogram.

⭐ Ureteral injury often presents subtly 5-10 days post-op with flank pain, fever, or watery vaginal discharge (urinoma), not immediate anuria.

CT scan of postoperative pelvic abscess

🩹 Management - Damage Control

Goal: Rapidly stabilize critically ill patients with massive hemorrhage by abbreviating the initial operation.
Indications: Hemodynamic instability, massive transfusion protocol activation, and development of the lethal triad.

Key Steps:
- Control Bleeding: Peri-uterine/pelvic packing, vessel ligation (e.g., uterine, internal iliac).
- Control Contamination: Rapid resection of necrotic/perforated tissue.
- Temporary Closure: Use of vacuum-assisted closure (VAC) or Bogota bag.

⭐ Lethal Triad: The vicious cycle of hypothermia (<35°C), metabolic acidosis (pH <7.2), and coagulopathy (INR >1.5). Damage control surgery aims to break this cycle.

⚡ Biggest Takeaways

Post-op fever follows the "5 W's": Atelectasis (POD 1-2) is most common, then UTI and wound infection.

Ureteral injury is a key risk during hysterectomy near the uterine artery ("water under the bridge").

Vaginal cuff dehiscence is a surgical emergency, presenting with a fluid gush and potential bowel evisceration.

Femoral nerve injury from retractors causes impaired knee extension and loss of the patellar reflex.

Obturator nerve injury from lymphadenectomy causes weak thigh adduction.

VTE (DVT/PE) is a major mortality risk; prophylaxis is critical.

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